Confidential in accordance with Penal

Code Section 11167.5 and/or WIC

Sections 827 and 10850.

Ex Parte Application

And Order

12/31/2099

1

Department of Children and Family Services /

Bureau of Operations

Regional Office Address

City, State, Zip Code

CSW Name

Phone Number

File #, First Initial, last Name

DSS No. (State ID)

Text in BLACK automatically populates when the document is created in

CWS/CMS. Complete your document by referring to the PURPLE text.

SUPERIOR COURT OF CALIFORNIA

COUNTY OF LOS ANGELES

201 Centre Plaza Drive, Monterey Park, California 91754

EX PARTE APPLICATION AND ORDER

Hearing Date Hearing Time Dept./Room Hearing Type/Subtype

00/00/0000 08:30 a.m. 000 Ex Parte Application

IN THE MATTER OF

Name Date of Birth Age Sex Court Number

Automatically Populates 00/00/0000 X X CK00000

This information will automatically populate from the Hearing Notebook and from the child’s

Client Notebook.

If it did not populate, enter the child’s CWS/CMS case ID number below the child’s name. If

there is more than one (1) child, enter the CWS/CMS case ID number for the oldest child only.

PARENTS/LEGAL GUARDIANS

Name/

Birthdate

Address/

Phone

Relationship/

To Whom

This information will populate if the parent/legal guardian’s information is correct and current

on CWS/CMS.

Child’s Name Court Case Number

Ex Parte Application

And Order

12/31/2099

2

A petition was filed on [Enter Date] under WIC Section 300 [Enter sustained allegations]. The child

was declared a dependent of the Los Angeles County Juvenile Court on [Enter Date]. The most recent

hearing date was [Enter Date] for a [Enter type of hearing].The next hearing is calendared on [Enter

Date] for a [Enter type of hearing].

REASON FOR APPLICATION

If DCFS supports the proposed vacation or excursion, enter:

“This matter is before the court to request the court’s permission to authorize the

child’s travel outside of the United States.”

If applicable, enter:

“DCFS is also requesting that DCFS be authorized to apply for a passport/visa on behalf

of [enter the name(s) of the child] and pay for the processing fee."

If DCFS opposes the proposed vacation or excursion, enter:

“This matter is before the court to oppose the proposed vacation or excursion.”

If the proposed vacation or excursion is with a party other than a parent, legal guardian, or

caregiver, enter:

“This matter is before the court to request the court’s permission to authorize or deny

[enter the name of the individual(s)] to take [enter the name of the child(ren)] on

vacation.”

If the request is to allow a child to spend vacation time with a relative/family friend residing

outside of California, enter:

“This matter is before the court to allow [enter the name of the child(ren)] to travel to

the home of [enter the name of the relative/family friend and his/her relationship to the

child] for a vacation.”

NOTICES

Name Relationship Method Date Agreed

Enter all individuals that were noticed, their relationship to the child, the method used to

notice them, the date, and a “yes” or “no” as to whether each agrees with the travel

recommendation.

REASON FOR RECOMMENDATION

If DCFS supports the proposed vacation or excursion, enter a brief explanation as to why the

planned vacation or excursion is appropriate, necessary and in the best interest of the child.

Child’s Name Court Case Number

Ex Parte Application

And Order

12/31/2099

3

If DCFS supports the proposed vacation or excursion but a parent opposes the vacation or

excursion request, include the above statement and information and provide a brief

explanation as to why the parent(s) opposes the vacation request. Include verbatim statements,

when possible. Enter the date, time, place of interview with the parent(s), and the parent’s

relationship to the case. If the parent was interviewed by telephone, enter the phone number.

If DCFS opposes the proposed vacation or excursion, enter the reason(s) the proposed vacation

or excursion placed the child at-risk and/or is not in the best interest of the child.

If the proposed vacation or excursion is with a party other than a parent, legal guardian, or

caregiver, discuss the home assessment of the individual. Indicate why DCFS supports or

opposes the proposed vacation or excursion with the individual. Provide a brief explanation of

whether or not the planned trip is appropriate and necessary and whether or not it is in the

child’s best interest. If applicable, provide a brief explanation as to why the parent(s) oppose

the vacation request. Include verbatim statements, when possible. Enter the date, time, place

the parent/legal guardian was interviewed, and his/her relationship to the case. If the

parent/legal guardian was interviewed by telephone, include a phone number.

If there is vacation request for a child to spend a vacation with a relative or family friend who

resides outside of California, provide a brief description of the results of the home assessment

and why the planned trip is appropriate and necessary.

Ensure that the report contains the dates of the child’s departure and return, the complete

destination address, a contact number, and the child’s method(s) of travel.

RECOMMENDATION

It is respectfully recommended:

That the child(ren) be permitted to travel as follows:

Destination

Accompanied By

(Name/Relationship)

Current Placement

Departure Date

Return Date

Parental Agreement

Means of Travel:

Child’s Name Court Case Number

Ex Parte Application

And Order

12/31/2099

4

Additional Information:

If DCFS supports the proposed vacation or excursion, select the following recommendation:

“That the child(ren) . “[enter name(s) of the child(ren)]” be permitted to travel as follows:”

Enter all information requested in this section.

If DCFS opposes a proposed vacation or excursion, check the “Other” box and enter the

following:

“It is respectfully recommended that [enter name of the individual and his/her

relationship to the child] be ordered not to take the child(ren) on a vacation to [enter the

destination] from [enter departure date] to [enter return date], pending further order of

the court.” If necessary, specify any further travel restrictions.

If the request is to allow the child to travel to the home of a relative or family friend for a

vacation or excursion, enter the following:

“It is respectfully recommended that [enter name(s) of the child(ren)] be permitted to

travel to [enter destination] to spend a vacation with [enter the name of the relative or

family friend and his/her relationship to the child] from [enter the date of departure] to

[enter date of return].”

If applicable, enter the following:

“It is respectfully recommended that DCFS be authorized to apply for a passport and/or

visa and to pay for the passport and/or visa fee for a child [enter child’s name(s)] and

that the child’s [enter one (1): parent, caregiver, Children’s Social Worker] [enter

corresponding name] be authorized to apply for the passport and/or visa.”

I Declare Under Penalty of Perjury that the Foregoing is True and Correct.

Executed at , California this day of , .

CSW Name, Title, File #, First Initial, Last Name, Phone Number Date

SCSW Name, SCSW, Phone Number Date

Child’s Name Court Case Number

Ex Parte Application

And Order

12/31/2099

5

[ ] Ordered as Recommended.

[ ] Order of the Court:

Judicial Officer

Date